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Briefing Paper

The reality is grim for thousands of survival migrants and refugees arriving and existing on the margins in South Africa.

In June 2009, Doctors Without Borders/Médecins Sans Frontières (MSF) released a report, No Refuge, Access Denied, which outlined the severe risks Zimbabweans took in order to cross the border, the dangerous conditions under which they lived once they reached South Africa, and their lack of access to health care.

Almost one year later, their situation remains dire. They still lack access to proper health care, shelter, and safety, while facing violence, police harassment, and xenophobic attacks. Formal legal status in the country is often difficult to obtain, if not impossible. Gangs prey on them when they cross the border. Many of these migrants and refugees, as well vulnerable South Africans, face further threats as they live in appalling conditions, particularly in derelict buildings in Johannesburg where they seek shelter.

MSF has been running two projects in South Africa since 2007 to respond to the health needs of survival migrants and refugees. The MSF clinic in Musina near the border with Zimbabwe and the MSF clinic in Johannesburg provide primary health care, mental health support, and referrals to hospitals and specialized facilities, including for chronic conditions such as HIV/AIDS and tuberculosis. In Musina, staff also run mobile clinics to nearby farms where many of these vulnerable migrants work.

This document focuses on the perilous journey undertaken by many people crossing into South Africa and the appalling living conditions they later face, as well as what MSF sees as their precarious health situation. As a medical organization, MSF continues to express grave concern for the health and lives of thousands of survival migrants and refugees.

The threat of sexual violence for those crossing the border from Zimbabwe must be acknowledged. They need access to a formal status to be legally allowed in the country so they are not forced to cross the border irregularly and be exposed to this extreme violence.

Access to both emergency shelter and primary health care should be ensured for survival migrants, refugees and vulnerable South Africans living in dangerous shelters in Johannesburg.

Musina: Fleeing hardship and crossing into uncertainty and legal limbo

Despite the establishment of Zimbabwe’s Government of National Unity in February 2009, people there are still living in a state of a humanitarian crisis and continue to flee daily across the border into South Africa. An average of 300 people a day, largely Zimbabweans, apply for asylum at Musina Department of Home Affairs Refugee Reception Office.

Among them are many unaccompanied minors, who are particularly vulnerable and have specific health, as well as safety and security needs. Most children cross the border alone—either because their parents send them to South Africa to earn money to subsidize their family, or to join relatives who have already arrived in South Africa. Many come looking for an education.

Getting into South Africa is a journey full of hurdles for everyone trying to cross the border from Zimbabwe. Obtaining a passport costs US $150, rendering it out of reach for the majority who are unemployed. People are forced to cross irregularly through the Limpopo River and the forest, placing themselves at risk of falling victim to violent criminals on both sides of the border. While the Department of Home Affairs promised a year ago to create a special dispensation permit to ease the process for migrants crossing the border, this has never been implemented.

In Musina, people can apply for asylum in South Africa in one day. This allows them to move on to other parts of the country before needing to attend an interview which determines whether or not they are granted refugee status. Some try to find temporary work on farms near the border. Less than one percent of applicants are granted refugee status at the end of the procedure. Those rejected have no formal legal status even if they cannot be deported at the moment.

Today, as there is no alternative provided, many people use the asylum procedure to have at least a formal status in the country temporarily. When those people return to their country of origin they lose their status as an asylum-seeker. This happens to many Zimbabweans who return home to bring money and goods to their families.

Sexual violence at the border

Sexual and gender-based violence has been occurring consistently along the border between Zimbabwe and South Africa for years now with virtually no coherent action by the relevant authorities. Criminal gangs known as guma guma rob women and men of their belongings before raping them. Often, more than one perpetrator will rape every woman in a group of people who have traveled together hoping for safety in numbers. Men are often forced to rape wives, sisters or aunts and if they dare refuse, they are raped by the guma guma.

“I crossed the river with a group of four people. We were met by a gang of seven guma guma on the South African side who were armed with knives and guns. They forced me to have sex with the women in my group and I refused. Then one of the guma guma forced his penis into my anus and ejaculated inside. I don’t actually know how many of them forced themselves on me because I was confused by the whole incident. I fainted and when I woke up they were nowhere to be found.”

– 27-year-old Zimbabwean man, patient at MSF clinic in Musina

When these severely traumatized people seek help, police in Musina are often unwilling to open a case of rape or indecent assault, saying the incident did not occur in South Africa but on the Zimbabwean side of the border and that the opening of the case would amount to a waste of resources as the survivors often move on to other parts of South Africa within days of the incident. However, at least 83 percent of the cases of sexual violence seen by MSF in the last three months occurred in South Africa. The large majority of these cases happen as people cross the border irregularly—a problem that would be eliminated if people could cross the border legally without a passport but with some other form of documentation.

Since the beginning of this year MSF has treated 103 survivors of sexual violence, 71 people since March 1 alone. Of these cases, 45 of the survivors were women and 26 men. Of these victims, 69 were Zimbabweans, one was Mozambican, and one was South African. Eight women are pregnant as a possible consequence of their rape. Only 56 percent of these cases were reported within 72 hours of the incident occurring, meaning only about half of those treated were able to receive post-exposure prophylaxis to prevent the possible transmission of HIV/AIDS within the required first crucial 72 hours after the incident.

“Condoms are never used in these rape cases. Many of the sexual violence survivors and the guma guma gangs are already HIV-positive. This means we are seeing a cycle of HIV spreading as different people in the guma guma gangs often rape the same women several times and the fellow travelers are also often forced to rape those same women. We cannot always give people post-exposure prophylaxis against HIV because they do not come to us in time. After they are robbed at the border they often first work on the farms and only come to Musina days later once they have earned some money. By that time it is too late to prevent HIV.”

– MSF counsellor working in Musina

Access to health care: Treating HIV/AIDS and tuberculosis in a highly mobile population

At present, MSF provides more than 2,000 medical consultations per month through mobile clinics at six farms in the Musina area and one mobile clinic at the Refugee Reception Center in Musina town.

The mobility of patients poses a challenge when it comes to treating the chronic illnesses, including HIV/AIDS and tuberculosis, which are prevalent. Antiretroviral treatment for HIV, as well as tuberculosis care, require that patients stay nearby for some period of time in order to access regular follow-up visits to clinics to get their medicines and to have their condition assessed by medical workers.

When people with HIV and tuberculosis are constantly on the move, it becomes extremely difficult if not impossible for them to remain adherent to treatment, especially when they are initiated in another country and carry no records with them when crossing borders. In a positive development to deal with this challenge, MSF and the Department of Health started a joint program in March of this year to provide decentralized care for HIV and tuberculosis patients in remote rural areas with a mobile population and a high number of workers from outside the country.

Johannesburg: Trying to survive in the shadows

Shelter

A year ago, the most well-known shelter for newly arrived survival migrants without established networks in Johannesburg was the Central Methodist Church, as outlined in the No Refuge, Access Denied report. Although the number of people seeking shelter in the church every night has reduced since last year, MSF estimates that upwards of 2,000 people are still staying there. This difficult living situation remains a serious health risk because of the overcrowded and unhygienic conditions.

The situation at the church has been partially addressed by the local and national authorities with the renovation of the Moth Building, a transit shelter which, when ready, is supposed to accommodate vulnerable migrants from other countries, as well as South Africans in need of shelter. With a capacity of 700 people, the Moth Building will be run with international funds, relocating only a portion of the most vulnerable people currently sleeping at the church.

In the past year, MSF has seen an increasing number of patients attending our clinic adjacent to the church coming from abandoned buildings in and around Johannesburg’s downtown core. These are the more than 1,000 buildings left derelict since the beginning of 1990s by their owners and progressively occupied by internal migrants coming from townships and rural areas and by refugees and survival migrants from other countries coming to Johannesburg. The majority of these buildings have private owners, while some of them are owned by the city.

Most of these buildings are hijacked by criminals or controlled by slum lords whose interest is to milk maximum profits from tenants while little or no maintenance work is done and basic water and sanitation services are in shambles or non-existent. This exploits vulnerable people who cannot afford or find any other accommodation or shelter in the city and puts their health at risk.

During outreach activities in the past year, MSF has independently identified 45 such buildings (former offices, industrial sites, or flat blocks) in the inner city where an estimated 30,000 people are staying in appalling living conditions. These spaces are overcrowded with subdivided rooms in warren-like conditions. There is very poor or non-existent sanitation, people have difficult or no access to water, and they lack proper waste management and disposal. All of these factors have a direct impact on personal and public health, including a significant effect on mental health.

“The quantity of rubbish is growing every day. Look at this big pile. You can see and hear rats moving around all the time. Can you imagine that here children are walking and playing and that in this room – just next to the rubbish – there lives a small baby just few days old? ”

– Mozambican man living in abandoned building

Most of the buildings identified are accommodating between 500 and 1,000 people, in some cases up to 1,500 people. They are mainly asylum-seekers and survival migrants coming from Zimbabwe but they are also from other countries, including Malawi, Tanzania, and Mozambique. South African citizens are also living in these buildings.

“I’m worried about outbreak of disease. There are not toilets in this building and so people defecate everywhere.”

–South African woman living in abandoned building

Even in these unacceptable living conditions, people are not staying for free. Rental fees charged by slum lords or gangs can be between 50 Rand per day (about US $6) to 750 Rand per month (about US $99).

At meetings MSF attended in the last seven months, chaired by the City of Johannesburg and shown on the city’s web site, Johannesburg has expressed a clear intention to tackle this issue, aiming to eliminate these buildings in the next few years with a program of renovation and beautification. But to date no real coherent plan of action has been put forward to either address this state of affairs or improve the conditions people are living in.

Between September 2009 and March 2010, MSF witnessed at least four evictions from buildings with a population between 700 and 1,200 people each. All of these evictions happened in the same way—private security companies, often one known as the Red Ants, and sometimes policemen were sent by the owner to chase residents out from the buildings with violence, using sticks and sometimes rubber bullets. Once out of the building the residents were not allowed to go back inside to collect their belongings, which were thrown out from the windows. In many cases, residents complained that their belongings were stolen by the security or police.

MSF treated several residents injured during those evictions for severe bruising and open wounds received from the beatings with sticks and from rubber bullets. During the last eviction, which occurred in February 2010, some people on treatment for chronic conditions, including HIV/AIDS, lost their medications and had to be reassessed by medical staff and then resupplied with drugs. This included a five-year-old child on treatment for HIV.

No strategy for the relocation of the residents in the building was implemented or even proposed. In the following hours, people tried to contact friends or relatives to find refuge in other buildings. Days after the evictions, hundreds of people—including pregnant women, children and people in critical medical condition—were lying on the pavement in the middle of the city with no access to basic necessities like toilets or proper food, exposed to weather conditions, unsafe, and uncertainty about their future. Residents were only allowed to re-enter the buildings after a South African legal organization took their case to court.

“The building owners, their security and the police came into the building, with the police asking people why they had gone back into the building. They asked people to move out of the building as they were not supposed to be inside. In the process they started to assault people beating them with the back of guns and batons. The police were shouting at people telling them to go back to their country.”

– Person evicted Feb. 16, 2010. This was the second set of violent evictions in this building since October 2009.

Medical conditions and access to health care

The main diagnoses at the MSF clinic are respiratory tract infections, diarrheal and gastro-intestinal conditions, skin conditions and stress-related ailments. Most of the diseases treated in the clinic are directly linked to unhygienic and overcrowded living conditions, and without a change to these conditions patients’ health will not improve.

MSF is alarmed by the high rates of tuberculosis diagnosed. During the last six months approximately 500 patients have been tested and 10 percent of them were positive for tuberculosis. As well, we see high rates of sexually transmitted infections, including HIV/AIDS.

Since the opening of the MSF clinic, the number of consultations have steadily increased, starting with 750 patients per month in early 2008 and reaching an average of 2,300 consultations per month in 2009 and 2010 so far. Initially the MSF clinic was primarily frequented by residents of the church next door. Today, more than 70 per cent of patients are coming from city’s derelict buildings.

This gives indications that there are many people in need of health care and although the primary health care access is guaranteed through a number of nationals directives, there are barriers preventing survival migrants and refugees from accessing public health facilities, so they come to the MSF clinic. Those barriers include language and inability to pay for consultations. Many patients at the MSF clinic say they are made to feel unwelcome in public health facilities because they don’t speak the local language.

In addition to providing basic health care and psychosocial support, MSF staff often accompany patients to existing health services in Johannesburg to make sure people receive the essential medical care they need.

“In September of 2009, I went to a public clinic because of an incomplete miscarriage but the nurse told me they only do abortions for South African people. After they asked for 400 Rand (US $48), which I didn’t have, I went to a N’anga (traditional healer) who helped me with the abortion. In November I went to the same clinic because I had severe abdominal pain. They asked me again for my passport and 140 Rand (US $15). I walked out and bought antibiotics and painkillers.”

– 28-year-old woman living in abandoned building

Police harassment

Survival migrants in Johannesburg face the threat of police harassment. On January 14, 2010, a joint raid was conducted by the South African Police Service and Johannesburg metro police outside the church. According to South African Police Service, 39 people were arrested for loitering. Those arrested included at least two patients who were queuing for treatment at the MSF clinic.

“Moving around, even doing shopping the South African or metro police are always after foreigners. They will definitely find a crime for you and ask you to make a plan (pay them), like giving them money, even as little as 20 Rand (US $2.40).”

– Zimbabwean man living in Johannesburg

Xenophobic violence

After the wide-spread outbreak of xenophobic violence, which erupted in 2008, refugees and vulnerable migrants have continued to be victims of violence. These instances may be on a smaller scale but the consequences are equally severe.

On November 22, 2009, more than 1,600 people, including 187 children, all Zimbabweans, were chased out by local residents from a different township in the suburb of De Doorns, in the Western Cape vineyard areas. Their shacks were destroyed and looted and most of their belongings destroyed. Locals were saying people from outside the country were taking their jobs by accepting work on farms as low-paid laborers. A campsite for the displaced people was set up by local authorities.

MSF was present in the campsite for two weeks providing medical care and trauma counseling. The attacks had a strong impact on the mental health of the displaced. Stress levels were very high, especially among those who had witnessed other attacks in February 2009 during which seven Zimbabweans were burned to death. Through individual and group counseling sessions MSF found a high level of anxiety as people did not know if they would be accepted back in the community or relocated. Their major concerns were about safety, security and being able to go to work.

The night of December 7, 2009, South African Police Service and Polokwane Municipality relocated more than 100 Zimbabweans living in a suburb of Polokwane to a nearby stadium. The relocation followed several hours of violence carried out by South African citizens against non-South Africans living in the community. At the stadium, MSF provided medical assistance to 13 people, including two children under three years old, as well as six people with severe violent trauma injuries. Many people said they experienced headaches, stomachaches, chest pains, difficulty breathing or nightmares soon after the attacks, all clearly related to the trauma suffered.

“A group of people burst into the house, breaking the door. They asked me to show them my South African ID, and when I said I didn’t have any, they started to beat me with sticks, stones, punches, kicks. I managed to escape from the house and started to run along the road, but they didn’t stop. They started to follow me with the car and let me run for a while. They caught me again and beat me up until I was lying on the ground covered in blood. They left me there because they thought I was dead. After a while I tried to move and with difficulty reached a phone box and called an ambulance. The ambulance didn’t arrive. Three people stopped their car when they saw me lying on the ground, carried me into their car and brought me to the hospital. This is not the first time. Last year, six people beat me up, but it wasn’t like now – this time they wanted to kill me.”

– 20-year-old Zimbabwean man in Westernburg, Polokwane

Many of our patients tell us they continue to worry about threats to their lives because of who they are, because of where they come from.

”I’m afraid of the xenophobia everybody says is coming after the World Cup.”

– 31-year-old Zimbabwean man living in Johannesburg

Conclusion

MSF speaks about what we see in assisting our patients in Musina and Johannesburg and what their vital health needs are. One year after the MSF report, No Refuge, Access Denied their situation remains dire and unacceptable.

Sexual violence occurring on the border or during the border crossing should be addressed by the responsible authorities in Musina and Limpopo Province. Zimbabweans need access to a formal status to be legally allowed in the country so they are not forced to cross the border irregularly and be exposed to this extreme violence, something which has been promised by the South Africa government.

Residents of derelict buildings in Johannesburg who are being evicted need access to emergency shelter that is clean, safe and meets basic standards of living. The Moth Building may hold promise for those currently staying at the Central Methodist Church, but this will not meet the larger needs, including those of the vulnerable South African homeless population, as well as those from outside the country.

While there have been some improvement in access to chronic care, there remains a critical need for greater access to primary health care for this vulnerable population.

“I came to South Africa in June 2008 after I was diagnosed as HIV-positive. I crossed the border through the river because I didn’t have documents. The guma guma assaulted me and raped me several times. They said to me, ’We rape you because you have to pay to us and you don’t have money.’ When finally they the let me go, I had to seek medical help because I was feeling very sick. I was admitted to the hospital in Musina. After I spent three months in town, I decided to go to Johannesburg, where I spent six months at the Central Methodist Church. I moved to the J.C. (an abandoned building) after I was diagnosed with tuberculosis because I needed a place to rest in the morning after taking my tablets. In September 2009, the Red Ants came to evict us from the building. Since then I’m staying at the M. building where I’m sharing a room with other 11 people and paying a rent of 80 Rand (US $9.60) per week. Now my wish is to buy a stove and start to bake for selling.”